Injuries to the Great Vessels of the Abdomen Presley Regional Trauma Center Department of Surgery University of Tennessee Health Science Center Memphis, Tennessee Introduction • Findings on PE depend on whether a contained hematoma or active hemorrhage is present • Those with contained hematomas may have only modest hypotension • Those with active IP hemorrhage have significant hypotension associated with abdominal distension Introduction • Secondary to penetrating wounds in 90 to 95% of cases • Often accompanied by injuries to multiple intra-abdominal organs • Occur in one of three zones of the RP or in the portal-retrohepatic area of the RUQ Injuries in Zone 1 Supramesocolic • It is helpful to divide midline RP hematomas into supra- and infra- mesocolic • With hematoma or hemorrhage in this area suspect injuries to – suprarenal aorta – celiac axis – proximal SMA – proximal renal artery Approach • Left medial visceral rotation • Allows visualization of the entire abdominal aorta from the aortic hiatus to the common iliac arteries • Can be helpful to transect the left crus at the 2 o’clock position – exposes distal descending thoracic aorta – cross-clamp Approach • Active hemorrhage can be temporarily controlled by packing or applying an aortic compression device • Divide lesser omentum, retract stomach and esophagus to the left • Dissect just below aortic hiatus of diaphragm to expose supraceliac aorta Technical Pearl • Cross-clamping of the diaphragmatic or supraceliac abdominal aorta in a patient with hemorrhagic shock results in severe LE ischemia • Restoration of flow then compounds the ischemic insult with a reperfusion injury that develops in the muscle compartments below the knee Technical Pearl • STRONGLY CONSIDER prohylactic 4- compartment fasciotomies prior to leaving the OR in these patients Management • Injuries to branches of the celiac axis are often difficult to repair because of the amount of dissection required to remove dense neural and lymphatic tissue • Injuries to the common hepatic artery may be repaired either via lateral arteriorrhaphy, resection+anastomosis or vein graft